Hold the onions: Training in an era of heightened diversity and expectations

In a recent interview published in Delta Sky magazine, Anthony Bourdain, author, chef, and host of the Travel Channel’s No Reservations, explained how the U.S. culinary scene has experienced a multitude of changes throughout the past 60 years—essentially a culinary explosion.¹ He recalled the complete absence of sushi or most other “non-American” foods in the Manhattan, NY, restaurants of his childhood; it was “ham with a pineapple ring” back then.¹ This is in stark contrast to the now commonplace appearance of sashimi, Vietnamese noodle bowls, tableside guacamole, or any other so-called non-American dishes on menus across the country. In not so many words, the food culture in America has likely adapted and incorporated more variety in the past few decades than in all of human history combined.

Mr. Bourdain described how this culinary revolution has resulted in a much more inclusive, worldly, and extensive array of tantalizing treats to spread across our palates. A few Sundays ago, as I was reading the interview and enjoying the most amazing French macaroons made fresh just two blocks away from my home, I thought of how the changes in medical education and patient-centered care have exploded in recent years as well.

History of medical education

Many of the changes in academic medicine date back to 1910, when Abraham Flexner conducted an observational study and later published a report on the state of medical education in the U.S. and Canada. Mr. Flexner essentially described the state of affairs to be equivalent to a Wild West show featuring a man with a monkey head trying to ride a unicycle while juggling flaming bowling pins. Many medical schools were termed “diploma mills.”² There was a complete lack of infrastructure and no standards for schools to follow to ensure medical trainees were being adequately taught. Not since Flexner’s landmark findings more than 100 years ago have such dramatic changes in medical education and training in this country occurred than as in the past 20 or so years.

As the American College of Surgeons (ACS) celebrates its Centennial year, now is an appropriate time to reflect on just how much has changed with regard to medical education and surgical practice over the past 100 years—and how much it continues to evolve.

Take for example, graduate medical education (GME) and even more specifically surgical education. Within just the past 20 years, the entire landscape of GME has changed. Surgical folklore recounts stories of case logs being inscribed on rolls of toilet paper and residents spending an entire week straight within the confines of their training institution, barely able to see sunlight through panes of glass—almost an eerie resemblance to penitentiary life.  The mantra of “see one, do one, teach one” was commonplace in the surgical training environment for decades.

Resident work hours are monitored more closely than ever; not only are trainees not to work more than 80 hours per week, but first-year residents are banned from spending more than 16 hours straight in a hospital.  Case logs are carefully entered into complex online databases with the capabilities to constantly update Current Procedural Terminology codes.  Expensive, high-tech computer simulators are now used as substitutes for live patients when interns perform their first case.

In the late 1840s, when a cholera epidemic was sweeping through the U.K., the scholars and physicians of the time believed that the transmission of the nearly always fatal disease was via a respiratory route. Fortunately, a surgeon named John Snow, MD, who later became recognized as the father of modern epidemiology, wrote the landmark book On the Mode of Communication of Cholera. In his book, Dr. Snow argued against the accepted dogma of a respiratory transmissible route for one favoring the gastrointestinal tract.³ Despite widespread opposition to his theory and public dismissal of it, Dr. Snow persevered, and eventually, history proved his logic to be correct. It is with time and increased breadth of knowledge that the medical profession has gained a far better appreciation for the work of Dr. Snow and countless other physicians and surgeons who faced similar difficulties in going against the norm, attempting to see a problem from a different perspective, or simply doing things differently.

Embracing change

Why are so many people resistant to change? I am the product of the work-hour restriction era in GME. My internship year, albeit seven years ago, was the first in which residents were mandated to work no more than an average of 80 hours in a single week. Since then, countless articles, editorials, surveys, and opinion pieces have been published by everyone from the youngest of medical students to the eldest of surgeons, all surrounding this radical change in the way physicians are taught in this country. Some of these individuals have been quite critical of these changes. Herbert Fred, MD, in an editorial from 2007, criticized work-hour restrictions, claiming that “we are exchanging sleep-deprived healers for a cadre of wide-awake technicians.”⁴ He wasn’t alone in expressing this sentiment.^5-7

Are these commentators really just concerned about change or have they created an environment similar to the one Dr. Snow encountered? To date, there remains a paucity of data to actually support the fact that work-hour changes have a clinical benefit. Yet some individuals would argue that there has been a positive effect, if none other than to make the choice of pursuing surgery more appealing to residents—men and women alike.⁸ I hope surgical educators 100 years from now don’t look back at the past 20 years in medical education and think we were similarly irresponsible for not more readily embracing the changes in the training paradigm.

The Hawthorne Effect

In 1950, Henry Landsberger was analyzing previous studies conducted outside of Chicago, IL, at the Hawthorne Works factory when he coined a now familiar term: the Hawthorne Effect.⁹ In the original series of studies dating back to the 1920s, workers in a factory were observed to see whether the installation of new light bulbs in the warehouse affected their productivity. Productivity did increase during the study period; however, upon completion of the study, when the workers were no longer being observed, productivity slowed to its pre-study pace even with the brighter bulbs. Thus, Mr. Landsberger hypothesized that the workers were becoming more productive simply because they were being watched, not because of the light amplitude overhead.

This example of human nature adapting under the auspice of awareness has been observed in multiple venues since the 1950s. Should we as physicians and surgeons expect anything different from the general public’s increasing observation of our professional results?  HealthGrades.com, UCompareHealthCare.com, and Vitals.com are three of the most prominent websites that rate patient satisfaction. (For more information about these sites, see the upcoming article in the September issue of the Bulletin.) The claim that these sites provide “outcomes” remains to be justified, as they are technically opinions and not verified outcomes measured against a standardized set of benchmarks. Our very own patients are taking the time to complete surveys online about how well we did: Was the physician’s bedside manner poor, good, or great?  How was the promptness of scheduling an appointment? These are just some of the criteria and measures upon which we are being compared; whether we choose to participate in these measures or not, the public will continue to report on their experiences.

Role of public perception

Should patient feedback affect our pay and delivery of care? I suspect that the Hawthorne Effect may not hold true in this realm as the equation for quality care is far more complex than public observation. However, physicians’ attempts to solve the equation must still place appropriate emphasis on this confounding variable. The role of public perception on physicians and hospitals has gained increasing ground. A 2010 article in the Journal of the American College of Surgeons is among the accumulating evidence that popular media and Internet-based quality ratings are increasingly important to patients.¹⁰

The simplistic or propagandistic model of online reporting, outcomes, and survey-driven websites are forms of democracy at play within the natural context and scope of society, termed social media. The antagonistic or, arguably, the theoretical model contends that these sites are attempting to change the hierarchal model of the medical profession.¹¹ Is it really just the profession of medicine getting in line behind the celebrities, book authors, amazon.com sellers, and pretty much anyone or anything else that has come under the scrutiny of the public on the Internet? Everyone has the right to voice their opinion, and, to continue the culinary metaphor mentioned earlier, “hold the onions” in the current state of affairs in the online kitchen. But is the medical profession held to a different standard inherent in a heightened sense of ethical and moral concerns in caring for a human being’s life? Herein lies a great discrepancy between medicinal care and thumbs up/down from a food critic.

Medical decision making is built upon a foundation of evidence-based literature and scientific conclusions, not on an opinion regarding whether or not a Le Plat Principal was too fishy tasting. David O’Connor, PhD, a scholar in bioethics at Johns Hopkins University, Baltimore, MD, wrote, “In this online environment personal experience (that of the patient) is sometimes valued more highly (more authentic and less mediated by professional stricture) than the expertise of the physician.”¹¹ Fueling the fire is the finding that many of these patient satisfaction websites are without an overseeing, editorial review process—allowing defaming comments to be posted and mar a physician’s record without any objective evidence to support the claim.

But why do patients run to these websites to vent their frustrations regarding a physician’s poor bedside manner and not report their concerns to a representative/authoritative medical body? Do patients have a sense of futility when they do complain to a state medical board or surgical society and feel that their voice isn’t being heard? Is this an area in which the ACS could play a proactive role? Could the ACS develop a national marketing campaign to increase the awareness of the importance of the physician-patient relationship or offer an official “postprandial” satisfaction survey? If consumers are disenfranchised with a surgeon, should the surgeon’s peers, colleagues, and trusted organizations be the ones handling the issue or should the issue be permitted to perseverate on the Internet? Could self-regulation really turn this issue around? The old adage “Trust me. I’m a Doctor” seems almost antiquated in today’s environment. In fact, Chantler and Ashton have suggested “a need to redefine medical professionalism given the changing roles of physicians and the increasing expectations of the public, and this in turn will have an effect on regulation.”¹²

The automaton theory

The increasing role of the health care consumer raises the question of how the medical profession is truly being run. Matthew Wynia, MD, MPH, a physician working for the Institute of Ethics of the American Medical Association, addressed the very real possibility that medicine is being transformed into a more commercial system. “Professionalism is a distinct ideology from consumerism, in which regulation of medical practice would be based primarily on expectations established by medical ‘consumers’ and implemented through competitive marketplace mechanisms,” noted Dr. Wynia in 2010.¹³ The results of various consumer-driven programs to rate and grade surgeons may be tied to the likelihood of whether a surgical practice will thrive or not. Jain and Cassel argue that physicians are becoming “automatons” whose actions are defined by external forces and public opinion.¹⁴ Is that why we have all traveled this long, and, at times, self-depriving road—just to become an automaton?

Public policy is increasingly supportive of the automaton theory. “Rather than being counted on to maintain their knowledge and expertise on their own accord, they [physicians] are subject to periodic examinations to demonstrate continued proficiency.”¹⁴ Are increased regulations for credentialing and recertifying really just a way to replace the self-motivation of surgeons to pursue continuing education and lifelong learning opportunities?

While I may be at an early stage in my career, I know that I will continue to seek knowledge to help care for my patients and remain at the forefront of delivery of quality patient care. I don’t simply owe this to my patients, but I have an internal drive to continue to honing my skills. Even without the increased requirements for recertification and continuing medical education documentation, I am responsible to myself and my patients to maintain and improve my proficiency. Other surgeons who I have encountered in my training have been tough on me at times, but, like so many other surgeons, no one is ever tougher on me than I am on myself. If this mind-set were to ever change, that is the day I would stop practicing the fine art of surgery.

In contrast to the increasing scrutiny surgeons are coming under from their patients, some have asked the reciprocal question: “When patients call, will physicians respond?”¹⁵ With the projected continual decline of physician reimbursements and the suspicion that surgical subspecialists will be the hardest hit in the pocketbook, will surgeons be willing and in some cases even financially able to care for the increased demand for services that is imminent when the Affordable Care Act is fully implemented? This conundrum is yet another ingredient in the recipe for medical care in the 21st century.

So tonight, as I make sure to not forget to add the extra pinch of Hawaiian Alaea Red Sea Salt to the chicken paprikash, I will be reminded of the increasing array of changes and adaptations we continue to appreciate in medicine, surgery, and GME. And while it may be a bit time-consuming and out of the way to stop by my local Sur La Table for that red sea salt, I will thank myself for doing it—for taking the time to educate residents under new guidelines and spend appropriate time with patients and their families. I’ll even go so far as to encourage my patients to fill out those online surveys.

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References

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4. Fred H. These are the days: The internship revisited. Tex Heart Inst J. 2007;34(1):3-5.
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11. O’Connor D. Rated negatively online? What’s a physician to do? Am Med News. August 22, 2011. Available at: www.amednews.com/article/20110808/profession/308089945/5/. Accessed June 3, 2013.
12. Chantler C, Ashton R. The purpose and limits to professional self-regulation. JAMA. 2009;302(11):2032-2033.
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15. Zinberg JM. When patients call, will physicians respond? JAMA. 2011;305(19):2011-2012.